Improving The Management Of

Deteriorating Paediatric Patients

“trust your intuition”

Dr Marino Festa

Paediatric Intensive Care Specialist

SCHN Critical Care Program Director (medical)

Think of the last unwell or deteriorating patient that you

looked after….

… how old were they?

Under 18 years?

18 – 48 years?

49 – 65 years?

65 – 80 years?

80 - 90 years?

>90 years?

How do these groups of patients differ?

Children - just small adults?

“…it is time to go beyond the “not just small adults” conceit….when trying

to convey to fellow health professionals and students the important

differences in paediatric practice, this conceit has the potential of becoming

vacuous and precious; and possibly deprives child medicine of significant

developments”

J Gillis and P Loughlan, Arch Dis Child 2007

Neonate................ Less than 28 days

Infant..................... 1 – 12 months

Child...................... Toddler: 1-2 years

Preschool: 3-5 years

School Age - 6-12 years

Adolescent............ 13-18 years

“Yet there is not so very much difference between the student who has to investigate the

diseases of children, and one who has to deal with those of the lower animals. In both cases

the diagnosis will chiefly rest upon the doctor's personal observation and examination; in

both it is intelligible speech that is wanting.”Sir James Goodhart, physician to the Evelina Hospital for Children in London from 1875 to 1889

Age appropriate clinical assessment

Outcome of Meningococcal Septicaemia in Children (Ninnis N, BMJ 2005)

Case-control study of childhood deaths from meningococcal disease, comparing

hospital care in fatal and non-fatal cases in the UK (1997 – 1999)

143 cases vs 355 meningococcal controls from same region

Multivariate analysis identified three factors independently associated with an

increased risk of death:

• failure to be looked after by a paediatrician

• failure of sufficient supervision of junior staff

• failure of staff to administer adequate inotropes

The odds ratio for death was 8.7 (95% confidence interval 2.3 to 33) with two

failures, increasing with multiple failures.

So how does the presence of a senior paediatric clinician

make a difference?....

Expert and competent non-expert visual cues during simulated diagnosis in

intensive care. McCormack C, Wiggins MW, Loveday T and Festa M. Front Psychol 2014

A comparison of expert and competent cue acquisition in a simulated complex, dynamic

and time constrained setting

Hypotheses:

• Experts process cues at a deeper level than by less experienced operators (sub-

experts) (increased dwell time / fewer saccades)

• Experts attend to fewer cues than sub-experts (fewer fixations)

• Experts and sub-experts will differ in prioritisation of cues (different main areas of

interest)

Methods

Setting

• Clinical bed-space in the paediatric intensive care unit at a tertiary children’s

hospital in Sydney, Australia

Participants

• Doctors working in NICU or PICU

• Range of experience and expertise:

• Experience working in intensive care: 1 – 35 years (mean 9.9, SD 10.3)

• Classified based on their occupational position:

• Trainees = Sub-experts (n=12): mean 4.8 (SD 4.6) years in ICU

• Consultants = Experts (n=6): mean 23.0 (SD 9.3) years in ICU

Study Design

Laerdal SimBaby

• Located in a normally configured cot-space in PICU

• Connected to an IV infusion

• Nasal prong oxygen

• Naso-gastric tube

• Resuscitation equipment available

Scenarios

• 2 standardised scenarios, each 3 minutes

• “respiratory deterioration in an infant requiring possible intervention”

• Scripted PICU bedside nurse participant

Eye Camera

IVIEW XTM HED (Sensometric) eye tracking system

• Scene video, eye tracking and audio recording

• BeGazeTM software to align longitudinal data with video footage for frame to frame analysis

• frequency of blinks• # fixations• # fast eye movements (saccades)• duration of fixations• areas of interest in the video scene (nurse, monitor, head, torso, legs,

wall)

Analysis of first 90 seconds for each video

Main Results (mean (SD))

Stress:

• No significant difference in # blinks

• sub-experts 88.3 (39.2) vs. experts 94.4 (28.9)

Expertise:

• No significant difference in # fixations

• sub-experts 75.2 (32.2) vs. experts 72.9 (32.0)

• No significant difference in # fast eye movements

• sub-experts 66.4 (27.2) vs. experts 57.8 (26.6)

• Significant difference in mean fixation duration (mS)

• sub-experts 470.4 (31.4) vs. experts 538.9 (56.0), p<0.05

Visual Areas of Interest(nurse vs. monitor vs. head vs. torso vs. legs vs. wall)

Significant relationship between expertise and areas of interest (F=3.331, p<0.01)

Significant difference in mean dwell times (ms) for mannequin’s face

• sub-experts 2868.1 (SD 4267.3) vs. experts 19611.7 (SD 12455.8), p<0.008

No significant differences in dwell times were observed for other areas of interest

• Between The Flags (BTF) is the largest and most comprehensive

system of its kind anywhere in the world.

• This program is intended to provide a safety net for

deteriorating patients.

Mandatory Calling – regardless of expertise

Initially 5

age-appropriate

colour coded

observation

charts

Standard

Paediatric

Observation

Charts

RR and unexpected

CPA rate per 1,000

acute separations,

Jul13 – Jun17,

Paediatrics Hospitals

NSW

Frequency of Single Activation Rapid Response Criteria by Age Category for ICU/HDU Admission (CHW 2012-2015)

Case 1:

• 11 months old

• Unwell 1 week “Hand, Foot and Mouth Disease”.

• More unwell and vomiting today.

• Brought by mum to Emergency

Department; admitted to the

Paediatric Ward this afternoon:

• RR 50/min• SaO2 98% (R/A)• Heart Rate 160 bpm• BP 120/70• CRT <3s• Temp 39°C axilla• Ulcers on mouth• BSL 6.1 mmol/L

Respiratory

• Rate

• Work of breathing / Respiratory Distress (SPOC table)

• Efficacy of breathing (air entry, chest expansion

• Oxygen Saturations

Trust your intuition?

Trust the parent or carers intuition